PAM™ Annual Review Questionnaire

PAM™ Annual Review Questionnaire

Complete this 3–5 minute check-in so your PAM™ can prepare for your annual Medicare review.
Your name

First NameLast Name
Have any of your doctors or specialists changed since your last Medicare review?
Doctor name, specialist, or concern (optional)
Have your prescriptions or pharmacy changed?
New medicine, stopped medicine, pharmacy name, etc. (optional)
How is your current plan working?
What, if anything, has been frustrating? (optional) Helper examples: copays, prescriptions, doctors, benefits, access to care.
When you think about your Medicare plan for next year, what matters most to you? (Select all that apply.)

Other
Has anything changed that might affect your Medicare coverage or how you use it?
Anything you want Sharon to know before your review? (optional)
When you think about your Medicare plan for next year, which TWO things would make the biggest difference to you? (Choose up to two.)
For example: keeping your doctors; paying less for doctor visits or prescriptions; lowering yearly out-of-pocket costs; a Part B giveback; or benefits you use, like OTC, dental, vision, and hearing.
Of these three benefits—dental, vision, or hearing—which is most important to you?
Your PAM™ will use these answers to prepare for your annual Medicare review. This questionnaire does not change your Medicare coverage or enroll you in a plan.
PAM™ powered by EUIB Assurance.
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